The Modern Care Management Team: Tools and Strategies Evolve, but the Outcomes Improvement Goal Remains

As he sips his morning coffee, Dr. Peter Touché reflects on his journey over the past few years. When he finished his primary care training in 2010 and joined a large health system’s medical group, a more modern concept of care management was beginning to emerge nationally. But his health system didn’t launch a more up-to-date care management initiative until two years later. Now, eight years after entering practice, that care management program is in full bloom.

The Modern Care Management Team: What Does It Look Like?

The care management team concept has significantly changed and expanded over the last decade. Rather than consisting primarily of himself and his office nurse, Dr. Touché’s panel of patients are now assigned to a considerably larger provider panel, which he leads. This provider panel consists of specialty physicians, care management nurses, therapists, social workers, nutritionists, educators, and others. When necessary, representatives from community support services become part of the team in collaboration with the nurse care manager.

Under Dr. Touché’s leadership, the care team and his panel of patients view each other as partners in care. With the care team’s support, patients are encouraged to enhance their roles in care planning, decision making, self-management, and the adoption of critically important health-related behaviors. Dr. Touché’s care team is characterized by important criteria, beyond simply being larger in size:

All team participants know and accept that they are part of a large and diverse team in service to patients.

Patients and their families are viewed as integral parts of the care team.

The care team depends on frequent, effective communication between each member, including patients and families.

The team has a comprehensive awareness of what each member is accountable for and what they are achieving to prevent gaps in care and avoid duplication.

Dr. Touché’s care team meets regularly to manage existing patients, assign new ones, and review and update assignments for each care team member based on each patient’s needs, values, and preferences. Tasks are assigned based on each care team member’s skills, abilities, and credentials. Care team members are guaranteed protected time to conduct activities beyond direct patient care, including continuing education to stay current with clinical advances and constantly updating clinical protocols.

The approach taken by Dr. Touché’s care team is consistent with the Agency for Healthcare Research and Quality’s (AHRQ) published definition of patient-centered primary care as “care that is relationship-based with an orientation toward the whole person, and that includes partnering with patients and their families to understand and respect each patient’s unique needs, culture, values, and preferences. Care that is patient-centered also supports patients in learning to manage, organize, and participate in their own care at the level the patient chooses.”

The modern care management team’s goal is to provide team-based care that is carefully planned, comprehensive, highly coordinated, data driven, evidence based, seamless, and patient centric in pursuit of optimal outcomes for the patients they serve—a goal that requires a comprehensive, effective care management system.

The technology to support care management begins with the EMR, but goes far beyond the mere digitization of a patient’s medical history. While EMRs are necessary sources for collecting and storing data, they are not the interactive workflow tool clinicians need for timely and judicious decision making. What’s needed is a suite of tools with features in all five core competencies of care management:

Data integration: The ability to pull data from multiple EMRs and other data sources, then aggregate, analyze, and make it available to the right people at the right time.

Patient stratification and intake: Using analytics-driven decision making to identify high-risk, high-utilization patients. This tool also supplies care managers with prioritized worklists for interventions, and greatly simplifies their work.

Patient engagement: Informing patients about their care planning and facilitating interaction among all care team members through application-based secure messaging, assessments, care planning and associated activities, and education.

Performance measurement: Advanced reporting capabilities to show how the care team performed after analyzing and acting on the data provided.

In addition to the tools comprising a comprehensive care management system, two other factors are important in determining the value and effectiveness of a care management system. First, the care management system must have access to all necessary data, including data from the health system’s EMR and other systems that provide operational, financial, cost, and satisfaction data. It is also important to include patient-reported outcomes (PROs) as they become available. Typically, this is data integrated in a well-designed enterprise data warehouse (EDW).

Second, the care management system must have advanced healthcare analytics capabilities. The system must be able to analyze data to figure out trends and patterns that drive better outcomes for patients and change the day-to-day workflow for clinicians. Embedding advanced analytics capabilities, including predictive analytics and machine learning, coupled with data-driven quality improvement methods is critical to success.

Because of this new care management model, Dr. Touché’s panel of patients has substantially expanded from approximately 2,000 to several thousand. Yet, despite this growth, he believes the care management team is delivering even better care—a significantly more satisfying type of practice than he experienced when he first joined the health system. He feels more in control and enjoys working with his peers on the care team. And, most importantly, objective data points to improved patient outcomes, especially for chronic disease patients.

As he finishes his coffee, Dr. Touché feels a deep sense of satisfaction. This is care management as it should be.

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